Gastroenterology Coding Alert

Entyvio infusions are common at GI practices, but remain a coding enigma to many people.

When you think about your most-billed codes, your mind probably goes to E/M services and colonoscopies, but the service that ranked second among gastro­enterologists’ most-reported codes last year was J3380, according to Medicare utilization data.

Unfortunately, J3380 (Injection, vedolizumab, 1 mg) is not the most straightforward code to report – it requires you to pair it with not only the right ICD-10 code, but also an appropriate administration code.

Background:  Entyvio (vedolizumab) is a drug used for patients with ulcerative colitis and Crohn’s disease, which the provider typically administers every eight weeks. Check out the following tips to find out how you should report these services.

Tip 1: Medical Necessity Is King When Billing Entyvio

Before billing for Entyvio, make sure you have fulfilled the coverage conditions for the service. For instance, in a policy last updated on Aug. 1 of this year, United Health­care stipulates the circumstances under which Entyvio is covered, including the following, among others:

• For Crohn’s disease initial therapy treatment:

            o Must have moderately to severely active Crohn’s disease
            o The patient must have a history of failure, contraindication or intolerance to at least one conventional therapy and/or must be cortico­steroid dependent
            o The patient receives up to 300 mg every eight weeks
            o The patient is not receiving Entyvio with TNF blockers such as Humira, and is not on Tysabri
            o Initial authorization can be for no longer than 14 weeks

• For initial ulcerative colitis treatment:

            o Diagnosis of moderately to severely active ulcerative colitis
           o History of failure, contraindication, or intolerance to conventional therapy
           o The patient receives up to 300 mg every eight weeks
           o The patient is not receiving Entyvio with TNF blockers such as Humira, and is not on Tysabri
            o Initial authorization can be for no longer than 14 weeks

Tip 2: Remember the Right Diagnoses

Make sure that you support the administration with allowed diagnosis codes for smooth reimbursement. Some examples of acceptable ICD-10 codes are as follows, according to a policy from Aetna:

• K50.00-K50.919 (Crohn’s disease)
• K51.00-K51.919 (Ulcerative colitis)

You should check your LCD guidelines for exact codes that are accepted by your payer and make sure the patient meets the coverage criteria before you administer the medication.

Tip 3: Pinpoint An Administration Code

The appropriate administration code will depend on how the medication is administered, but in most cases, you’ll report 96365 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour) to represent the infusion of the medication.

Tip 4: Know the Dosage Rules

When reporting J3380, keep in mind that you’ll report one unit per milligram administered, so make sure you specifically check the number of units on all of your claims. Most payers will impose limits on how many units they’ll reimburse, which is often 300. So if the physician administers 300 mg, report 300 units of J3380 on the claim.

Tip 5: Avoid 99211 With Entyvio Claims

Some practices tend to tack 99211-25 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional…;) (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) on to each Entyvio administration, but that’s not necessarily a smart idea.

Here’s why:  Although Entyvio services require more dose preparation than most average therapies, the problem with using 99211 for Entyvio administration is that payers already include dose prep and routine patient assessment and monitoring in the payment for the infusion code 96365. Therefore, do not report this code for Entyvio administration.

Check Out a Case Scenario for Correct Implementation

Unsure of how to put all the elements together? Check out the following example.

Scenario: A corticosteroid-dependent patient with severely active Crohn’s disease of the small intestine (with rectal bleeding) presents to the gastroenterologist for Entyvio treatment. A nurse infuses the patient with 300 mg of Entyvio under direct physician supervision and the patient returns home subsequently. You may therefore report:

• 96365 for the infusion administration
• K50.011 (Crohn’s disease of small intestine with rectal bleeding) to note the patient’s diagnosis
• J3380 x 300 units for the supply of Entyvio

Always remember that infusions require direct supervision of the staff member who is performing the administration, so be sure that a physician or advanced practice provider is in the office suite at the time of service.

If a same-day E/M service is required, the physician should document the visit separately (including the reason the E/M was required)

and report it with an E/M code (99212-99215) and report modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to indicate it was a separately identifiable service.